Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Provider

Professional or facility-based providers are faced with segmented operational structures that prevent a fluid communication of all relevant patient information while providing ongoing services. The providers’ role is often complicated by managing the relationship between their patients and the contractual arrangements that their patients may or may not have via their employers’ carrier or independent policy purchase. In addition, providers are also subject to separate contractual arrangements that they may have with respective payers (third-party administrators—TPAs).

Most providers are moving forward with initiatives to adopt electronic health records. They will continue to face challenges in this arena. In particular, current offerings appear to be deficient in terms of front-end and back-end operating functions. For example, when a health information management department of a hospital receives a request for release of information, the labor involved in generating a production of a one-week hospital stay can take two to three hours. In addition, many current programs have limited options in terms of exporting content in a user-friendly format.

This market continues to struggle with reimbursement issues between the patient and the payer. Examples of provider facilities include professional offices, clinics, inpatient facilities, outpatient facilities, home health settings, nursing homes, and rehabilitation centers. The current market focus is on price transparency ...